Continuous Quality Improvement

Progress In Quality Improvement

Our goal at Blue Cross NC is, "To help increase the health and wellbeing of our members." So you might be wondering:

How do we meet our goal?

We meet our goal by:

  • Reviewing our quality activities
  • Analyzing our member programs and offerings
  • Making sure that care is based on strong clinical evidence
  • Communicating more clearly

What makes up quality of care?

Our quality of care model is based on many factors. The diagram below illustrates these.

Progress In Quality Improvement

How do we determine the quality of services we provide?

  • We apply for quality accreditation
  • Quality accreditation is an official recognition that shows a health plan's commitment and level of quality
  • We work with the National Committee for Quality Assurance (NCQA) to increase health care quality across our company. NCQA analyzes and publishes the quality levels of the nation's managed care plans

Why is this important to members?

  • NCQA accredited health plans face a thorough set of quality standards
  • Health plans must meet the NCQA quality standards to earn NCQA's seal of approval


As shown by our ranking, we are committed to health care quality. We strive to have the best health care quality and service in North Carolina. In order to do this, Blue Cross NC follows a continuous quality improvement model. The model has three steps:

Develop a Quality Improvement Plan

  • The Quality Improvement Plan is developed to make sure we are meeting the needs of our members. It is created each year.
  • The plan includes quality-based initiatives to improve the health care experience of our members.

Monitor and Measure

  • Once quality initiatives are put into action, they are monitored and measured to make sure all parts of the plan are put into place.


  • Every year, initiatives are evaluated to see how well they performed. We measure if goals were met.
  • Helps identify focus areas for the next year.

2015 Summary of Quality Accomplishments

There are many categories of quality initiatives, as illustrated below. We also have details about our quality improvement activities for this year in the next section.

Clinical Quality & Safety of Care

Initiatives designed to:

  • Guarantee medical and medication safety
  • Use preventative services
  • Improve health of members with chronic conditions

Member Experience

Initiatives designed to:

  • Improve how we communicate
  • Help members understand their benefit plan
  • Help members make choices to better manage their health

Provider Quality

Initiatives designed to:

  • Measure the performance of doctors and other healthcare providers
  • Increase quality standards

Clinical Quality & Safety of Care

Examples of initiatives under clinical quality and safety of care are shown in the diagram below.


Healthy Outcomes Program:

Blue Cross NC offers health and wellness programs to help members improve their health. Members receive materials and tools. They may also get tele-monitoring services. These services include a monitoring device that answers symptom questions. The data is then transmitted to Optum wirelessly or via a telephone line. This program helps members stay up-to-date on needed health screenings and services.

Blue Quality Physician Program (BQPP):

This program is used to identify and reward practices. Practices are rewarded based off of the following:

  • Commitment to patient-centered care
  • Leadership's dedication to quality
  • Improvement in health outcomes
  • Reduction in costs

A mandatory element in the BQPP program is the NCQA Patient-Centered Medical Home recognition. The main focus of this recognition is quality and efficiency. The number of BQPP practices is still growing in North Carolina. We will continue to demand higher quality from our providers. They will help make sure we deliver the best health care possible.

Diabetes Progress Report and Patient Reminders:

Blue Cross NC mails reminders for preventive services to members when records indicate missing services. In addition, the Diabetes Progress Report provides members a report of services they have received, and more importantly, the report reminds members of services that are still needed.

Patient Care Summary:

In 2014, we gave physicians Patient Care Summary (PCS) reports. The PCS is a report that shows physicians the services their members need to have completed. In 2014, more than 10,000 providers* had access to the PCS. Also, nearly 52,000 PCS reports have been accessed by Blue Cross NC providers*.

*Providers include doctors, specialists, and hospitals. From this point forward, when we talk about doctors we are referring to doctors, specialists, and hospitals.

Member Experience

Examples of initiatives member experience are shown in the diagram below.

Member Loyalty Program:

We introduced a new member reward program based on if members completed a Health Risk Assessment (HRA). The rewards included gift cards and premium cards. Premium cards help reduce the amount members have to pay for insurance.

Consumer Assessment of Health Care Providers and Systems (CAHPS) Survey:

This survey asks groups of consumers and patients to report on their experiences with health care. The 2015 results showed that we declined slightly in the Overall Health Plan Rating from 2014 results. This was expected due to the changes in the insurance industry. Based on these results, we focused more closely on how we can improve this rating in 2016.

Provider Quality

Examples of initiatives under provider quality are shown in the diagram below.


Patient-Centered Medical Homes (PCMH):

A PCMH, also known as a "medical home," allows members to get a large variety of services under one roof. Both physical and mental health care are available to meet members' individual needs. This leads to less wait time for members to get the care they need.

Provider Quality Reporting:

Provider quality reporting is based off of Quality Care Gap reports. These reports allow comparison of practice performance against national performance metrics. These individual practice, monthly reports allow providers to see the past 12 months and the predicted future year's Care Gaps for both Commercial and Medicare populations. The reports include detailed patient level data. This data is used to assist in closing care gaps and assure patients get the care they need. We continue to partner with doctors to improve the quality of care,

Blue Distinction Center (BDC)

We participated in the Blue Distinction Center recognition program for many services. This national program identifies service areas of organizations that have met quality and cost qualifications. These service areas provide better outcomes to members. There are BDC programs in various counties and hospitals throughout North Carolina.

Provider Tiering

The Tiered Network Program provides quality and cost information to consumers. This information allows consumers to make informed choices regarding medical care, thus impacting healthcare cost. Our methodology and data provides physicians with access to information on how their performance compares to their peers. This comparison is based upon quality measures and cost efficiency benchmarks. Provider Tiering information is reviewed annually.

2015 Program Evaluation

Blue Cross NC evaluates the overall effectiveness of the program on an annual basis to determine if changes need to be made. Resources were found to be adequate in 2015, therefore no changes to the quality committee structure, program resources, or practitioner involvement will be made in 2015. Changes to the 2016 Quality Improvement Program will be made to incorporate requirements, resources, and additional delegations for the Federal Employee Health Benefits Program.

Our approach in 2015 focused on making the member experience better and working more closely with doctors and outside organizations to increase overall quality. For 2015, we were ranked the #2 health plan in North Carolina.

2016 Goals

What do we plan on doing in 2015 to increase the quality of care our members are receiving?

The diagrams below show the quality initiative goals for each category.

2016 Clinical Quality and Safety Care Goals

Pharmacy Program

  • To create a pharmacy program for those taking certain medications
  • Will help make sure medications are taken as they are supposed to
  • Will improve member's health

Quality Messages from Doctors

  • To make sure doctors are advertising excellent quality
  • Will develop HEDIS tools for doctors to make sure they are giving members the right quality messages and goals
  • Tools will give doctors administrative help, offer guidance, and resources


  • To increase the rates of eight measures for our 2016 HEDIS submission
  • Will create initiatives in order to provide needed care to all members
  • Will allow doctors and Blue Cross NC to get the quality scores they deserve

Federal Employees Program

  • To get quality accreditation for the Federal Employees Program (FEP) PPO product
  • Will line up with the FEP PPO product up with NCQA standards for quality accreditation

2016 Member Experience Goals

CAHPS Survey

  • To act on results of commercial CAHPS and Marketplace Enrollee Experience surveys in a timely manner
  • Member responses will help determine how we can help members have positive experiences
  • Will use questions to maintain the Health Plan Overall Score and increase other ratings

Online Directory

  • To update the Web-Based doctor and hospital directory
  • Will allow members to easily find and use the directory information

Language Simplification

  • To allow members to understand written member materials more easily
  • Will simplify member communications
  • Will write member communication materials in a 6th-8th grade level

2016 Provider Quality Goals

Integrated Quality Plan

  • To collaborate between multiple teams to improve quality
  • Will lead to a provider reimbursement strategy
  • Strategy will encourage and reward providers who meet certain quality metrics in their contracts

Blue Quality Physician Program

  • Developed a quality metrics scorecard of 4 to 5 metrics for practices to focus on bringing their numbers up to the 75th or 90th national benchmarks for 2017
  • Added Advance Care Team element for practices build a team-based model in their practice (health coach, care manager etc)
  • Add more focus on Patient Access - after hours on week days and/or weekends

Provider Tiering

  • To continue the specialty provider tiering program with the current 7 specialties
  • Continue promoting high quality, cost effective health care
  • Focus on program improvement and enhancement

Blue Distinction Center

  • To continue to participate in the BDC recognition program
  • Survey will be given out about the future BDC maternity specialty program

Provider Quality Reporting

  • To expand the provider quality reporting programs by adding extra health care related measures
  • Will let doctors to compare themselves with others in the same specialty and to national metrics